Provider Demographics
NPI:1124580543
Name:BOURNE, LARINA
Entity Type:Individual
Prefix:
First Name:LARINA
Middle Name:
Last Name:BOURNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 E 149TH ST FL 5C
Mailing Address - Street 2:RM 168
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5589
Mailing Address - Country:US
Mailing Address - Phone:718-579-6536
Mailing Address - Fax:
Practice Address - Street 1:234 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5589
Practice Address - Country:US
Practice Address - Phone:718-579-6536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI0674851835P2201X
390200000X
NYCI0674851835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program